We know plenty of strategies for engaging our trauma patients. But do we know what to avoid?
How to help patients heal is not always clear. And trauma patients, given all their diverse history and symptoms, can be some of the most challenging.
So it almost goes without saying that, when working with clients who have experienced trauma, there are extra precautions practitioners need to consider.
Let’s take eye contact for instance.
While many of us would say eye contact is essential, Stephen Porges, PhD has written about the importance of averting eye gaze when working with trauma patients.
Direct eye contact can be interpreted as threatening and may trigger a negative reaction from someone who has experienced trauma.
In his book, The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation, Stephen describes what happens to the social engagement system of trauma survivors.
Trauma can turn off the social engagement system. Attempts to engage a person with trauma history, rather that eliciting spontaneous social behavior, may trigger defensive and aggressive behaviors.
From a clinical perspective, traumatized individuals often present features of gaze aversion and flat facial affect. If we were to monitor the physiological state of those individuals, we would observe an ANS (Autonomic Nervous System) that is poised to fight or flee (i.e., high heart rate and low vagal regulation of the heart). The traumatic experience functionally retunes neuroreception to conservatively detect risk when there is no risk.
Most therapeutic strategies attempt to engage with direct face-to-face eye contact. Working with traumatized individuals creates a great challenge to therapists, since the normal social engagement behaviors of the therapist may trigger fear and reactive defensive strategies.
But this precaution leads to a new problem.
If we avoid eye contact, how else can we engage with a client?
Dr. Porges offers a solution that involves an entirely different sense all together. This is a strategy you might not have considered.
Music therapy provides a special portal to reengage the social engagement system that does not require an initial face-to-face interaction. Music can be used to stimulate the social engagement system without requiring face-to-face reciprocity. Since melodic music contains acoustic properties similar to vocal prosody, music may be used to recruit the social engagement system by challenging and modulating the neural regulation of the middle ear muscles.
If the social engagement system is effectively recruited, positive facial expressions will emerge, eye gaze will spontaneously be directed at the therapist, and the traumatized individuals will shift to a more calm and positive physiological state.
Through the use of music therapy, it’s possible to stimulate a patient’s social engagement system without triggering defensive behaviors.
So, to get to the eyes, you could go through the ears.
Intrigued? I was.
To find out more, you might want to check out Stephen’s book, The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation.
Stephen Porges is the creator of polyvagal theory, Distinguished University Scientist at the Kinsey Institute at Indiana University Bloomington, and Research Professor in the Department of Psychiatry at the University of North Carolina at Chapel Hill.
We’ve talked with Stephen before about how the polyvagal system can help us understand reactions following trauma. His research is often illuminating.
He’s also a profoundly wise person, and I’m always glad to share his thoughts with you.
What are some techniques you’ve used with trauma survivors to avoid triggering a fear response? Please share your thoughts in the comments section below.
Eye contact from male or female can trigger me. Mostly men but now that I’ve been retraumatized by women their gaze affects me too now. I avoid all eye contact with everyone. I’ve just started being able to look at my therapist and there are moments where I can’t. My boss and coworkers don’t get it. They think I’m a crazy stuck up b——h. They know I’m a trauma victim but don’t understand on what to do which I totally get. Bright blue eyes are highly triggering as it is the eye color of the md that sexually assaulted me while I was supposed to be out cold. I notice everything from facial expression to twitches to lip positioning to someone chewing the inside of their mouth. I read their body language too. How to get over this??? It’s so tiring on a daily basis.
Trauma informed yoga also works well with traumatized children where the need for direct eye contact doesn’t provoke stress or anxiety
Very interesting to use the ear to get the eye… Thank you !
I like the idea of music for traumatized clients.. Looking forward to trying it. Thanks
As a woman my eye contact is not as threatening as a man’s. So I have not had the same experience as Porges. Often clients avoid eye contact because they are feeling shame. When they can look me in the eye I know the shame is lifting
Great article
I speak as the former client of a counsellor who coerced me into talking about my trauma and when I refused, he allowed another party to speak for me. It went downhill from there and it took me a year to recover enough to start therapeutic work again.
I am very glad to see that this kind of work is being done and wanted to offer my respect and gratitude here. Thank you. You are changing lives for the better.
Can we say that listening to music has therapeutic value? What does the therapist add to the mix? Awareness? Focusing attention?
I have found great results with EMDR
Stephen Porges complex researches are incredibly validating in the domain of coregulation. Creativity is a mean for client to express freely and within a outer boundaries that respect their inner child world. Turning inside to find inspiration and master the task can be similar to meditation and calming for when working with trauma without triggering fear.
Art Therapy helps with this challenge as well. The client is focused on the art they are creating from the inside out. There is no need for direct eye contact. It takes the stress of eye contact out of the picture and allows expression through the art.
That is very true as after I had suffered a cerebral aneurysm which was obviously significantly traumatic to my brain, I engaged in some art therapy for a time and it’s only now that it has come back to me & made me realise that it made me feel greatly at peace after those particular sessions. The sessions likely helped me get to where I am now in my recovery which is to me sort of average! My sister tells me I have improved lots since first coming out of the aneurysm and after significant rehabilitation!! I need to be told by others as I can’t really judge for myself. It’s really like I’m a completely different person compared to what I was before this event and I suppose I am really! It’s quite bazaar as I need to have my old self compared to my new one to see who I am really. I never really lost any ability with reading and writing so it’s much easier for me to communicate through writing rather than speaking where things get a bit stuttery & stammery making it difficult for me and for my companion!! Not much about art work in this comment but I think overall that it did contribute to my overall recovery! I can’t remember too much about it only that I did it and felt a bit silly really, like I was back in kindergarten!! It helped absolutely.
Lucia Capacchione – I discovered your book “The Power of the Other Hand” in 1990 after my husband was killed in an accident caused by a mentally disturbed person on an airplane. Using my “other/left” hand, helped me get to some really deep emotions that I could not have accessed, I think, in any other way. I did it alone. That journal has actually helped other people as well. I even looked into training with you. Thank you so much for your very deep process. Marcia Girardi
Fascinating research. I use EMDR and incorporate a light bar with vibrating paddles and a head phone that has an alternating beep.
Stephen Porges should get in touch with Shapiro (the psychologist that developed EMDR) as this is such a remarkable finding. The fact that there is no eye contact with EMDR could be one of the reasons it works so well.
Also, Stephen Porges should also check out EMDR
I’m sure Dr. Porges is very familiar with Emdr and it might be difficult to get in touch with Francis Shapiro since she passed away.
Emvarrassing that you advocate EMDR yet do not know Francine Shapiro died not long ago.
It’s not embarrassing that that person didn’t know that she died. It’s embarrassing when you are unkind to somebody who does not have information that they have and then you shame them. I understood what the other person was saying. I have also thought that the combination of polyvagal theory and EMDR would be amazing, so yes I agree that Porges could get to know EMDR and do some work around that, or someone else even could. Porges and Shapiro’s work are both amazing. I’m sure there are people that are putting some of that together.. I’m excited to hear more.
And why Gertrude should she know that he passed? Just because she has liked and uses his technique doesn’t mean she checks up on him on a daily bases. She may not know him personally. It’s like remembering a book you read long ago and it helped you through life and you want to share this with others so you tell them about it. Granted I might not say reach out to the author, but she may have in the past and has been successful with it. No harm done. This person she told or you could have just told her that he has recently passed so she would know not to reference him again like that. Just saying that, if something like that comes up again, she will most likely check on it first before saying something again. You learn from your mistakes and move on. No need to make her feel bad about it. Sorry I don’t normally say anything.
Totally agree with you, Sarah. Best way to introduce especially children to new ways to concentrate and create while keeping thinking on their feet. Missed the opportunity to be a music or arts therapist but I use the same concept when teaching in my classroom. Doing it with the soft music in the background is also much better.
Thank you for sharing about music! My trauma clients seem relieved and relax more when I assure them that we’ll go slowly in our therapy. I strongly encourage them to let me know if they feel we’re beginning to go too fast.
The short Case Study in this article on working with traumatised youth is about exactly this – using music as a way to calm the triggered nervous system. Very interesting.
Very interesting, indeed. Love this site. Thank you.
So, how would you do the close-up “head-to-toe” assessment to see if there is no sensitivity or lack of the daily light that might be the cause for seasonal depression?
Discomfort due to eye contact can be caused by a wide range of circumstances. It may replicate the eyes of an abuser or suggest scrutiny and judgment or it may seem like an invasion of space like the kind of discomfort one would feel when someone else stood much too close when talking. It may not even be related to psychology but more to neurology. People tend to look In certain directions when processing specific types of information, when calculating sums, for example, or just attempting to process thoughts or feelings internally in order to better communicate. Alternatively, another person’s face and visual expressions may just be distracting, rather than threatening. Similarly, sound or touch or odors or even taste may connect or disconnect one person from another. Imagine sharing an ice cream cone with a client in your office and how that may connect or disconnect a client-therapist relationship. Although I do not recommend sharing ice cream cones in your office, it may be the explanation for why some therapists serve tea. My main point is that your decision of how to handle eye contact should be related to the etiology of the meaning of eye contact for that specific client.
I work creatively, which means that the client and I are attending to the creation (e.g. drawing, sand tray) together rather than looking at each other. That usually makes it easier for the client to symbolise and share difficult material in order to process it
I have music in the waiting room before I see clients. They never mention the music however when they come into the office they appear more relaxed. Stephen Halpern’s music is wonderful.
Thank you for the wonderful sounds. I am listening to Stephen H. music right now and it is profoundly calming. Also one of my favorite is by Ilchi Lee, “Bird of the soul”; we use this during our yoga session. It comes with a very easy guided meditation CD to follow. It may be avail. on Amazon.com as well.
That is really weird . I often get anxiety attacks while trying to maintain eye contact. I am a covert narcissistic abuse survivor.
ImaTattooOnHisPalm.com
Guided imagery very carefully developed with eyes closed and with client creating safe images, and with a keen therapeutic observation of facial and bodily signs of stress so breathing can be interspersed. Also the use of drumming duets of beats to the heartbeat first followed by more complimentary rhythms created by listening to each other and interacting in drum beats.
Sitting to the same side of the table/room. Then “putting” the problem there (in a drawing or as a metaphor) and look together in that same direction. Not look at client as if to find the problem there. Client is facing a problem, so am I now…Let’s be in this together.
I like your description of this Rens and do this on occasion when it seems to fit. I’ve done this kind of approach with couples at times too.
I had a patient, a victim of terrible domestic violence suffering quite a few serious facial and body fractures, who just stared at the opposite wall with a totally expressionless face. I referred her for Trauma Release Exercises with a local physiotherapist. Afterwards, not only I but also her solicitor could converse with her normally. She even began to laugh and smile again.
Body language mirroring via a gentle tai chi approach of response movement and mindful 4.7.8 breathing technique for managing those with irregular breathing and counteracting transference. Then when applicable to teach these techniques to clients. To give eye contact but remove eye contact to give space and develop a pattern whereby the client realises that you consistently remove your focus to give them space sends them subliminal and eventually conscious messages that you are aware that eye contact is difficult for them and that you are aware of this. As trust grows it is possible to linger and eventually meet eyes for a nanosecond. Over a number of sessions this can gradually develop through the trust of non imposing engagement.
I sit at an angle.
Although I move my gaze from time to time to notice any shift in flat facial expression .
Have not used music but do know certain classical pieces that change the mood
Query prosody or just subtle changes in Social Engagement System in Humans !
Thank you for all the great comments, particularly when music can work for some people but not for all.
In my practice I often avoid direct eten contact. This was installed due to my working as a physiotherapist in rehabilitation. I often sat lower than the facial contact area during the sessions or was not able to look . So I am used to listen to the vocals and all other expressions in the sound . I myself have to force to look the client directlyin the eyes normally. So I am blessed in this way in a naturally way.Hans Samson SEP
We who work with teens often say that it is Perry’s thoughts of parallel activities that promote deeper or more revealing conversation between parent and teen when the two are talking side-by-side (cooking together, washing dishes, etc) rather than talking face-on. I do believe that the activity of “doing” together rather than just “talking” together helps to open emotional sharing in the space between people. But I agree that unintentional lack of eye contact can facilitate emotional sharing, too. Making this part of your therapy practice has been a part of many of our procedures for years, and works well. I think that is the reason some of us write notes while clients open up, rather than “stare” at them as they talk, even though at times note-taking can be upsetting to clients and must be moderated, too. I love Porges’s Safe and Sound protocol — another example of “ear-before-eye”!
Lark Eshleman, PhD, Executive Director, About Child Trauma Foundation
Porges states that “music may be used to recruit the social engagement system by challenging and modulating the neural regulation of the middle ear muscles.” The middle ear has only two muscles, which activate only in response to loud noises, dampening hearing in a protective function. I’m not aware of any way for these two muscles to interact with social engagement, as they function involuntarily, triggered by loud noises. I’m also unsure of what Porges means when he talks about challenging muscle regulation. I would be very interested in clarification.
As a long-time clinician, I have known this intuitively- the part about eye contact- it’s always great when science supports intuition! And I have many musical skills – so this wonderful information. How can I share on Facebook?
Lessons learned from NICABM courses:
Be aware that a warm, friendly introduction may be threatening to a client whose perpetrator was warm and friendly.
Allow the client to choose their seat and ask if it is comfortable for them.
Place therapist/client chairs at 45 degrees rather than directly facing each other.
We who work with teens often say that it is Perry’s thoughts of parallel activities that promote deeper or more revealing conversation between parent and teen when the two are talking side-by-side (cooking together, washing dishes, etc) rather than talking face-on. I do believe that the activity of “doing” together rather than just “talking” together helps to open emotional sharing in the space between people. But I agree that unintentional lack of eye contact can facilitate emotional sharing, too. Making this part of your therapy practice has been a part of many of our procedures for years, and works well. I think that is the reason some of us write notes while clients open up, rather than “stare” at them as they talk, even though at times note-taking can be upsetting to clients and must be moderated, too. I love Porges’s Safe and Sound protocol — another example of “ear-before-eye”!
Lark Eshleman, PhD, Executive Director, About Child Trauma Foundation
I did a session once with my SEP with my hands in front of my face and another time with a blanket up to and over my chin and then my eyes downcast towards the floor. It was so liberating and since then I am very aware of my clients impulses to hide and not make direct contact. This also gives the client the message that I don’t need anything from them. They can rest in any way that feels safe. This takes time.
Direct eye contact can be seen as part of the “hard wiring” of the survival mechanism of the brain. Working with traumatized client means that often we are working with someone who is constantly “scanning” for threat and therefore can experience direct eye contact as a threat. I use brainspotting to work with clients. With some clients, “gaze spotting” (where there client finds their own eye position) is often also empowering. Porges’s theory can be applied to other non traumatized clients as well. When providing conflict resolution. we are taught to first break eye contact which deactivates initial threat. I find that is working with teenage boys, direct eye contact is often also seen as a threat. I suggest to parents that they talk to their teenagers while in the car where there is no direct eye contact. In brainspotting (as well as EMDR) we are trained to use bilateral music. Instead of putting earphones on clients, I put the music on in the background where we can “share” the experience of listening to the music together. Engaging and sharing other sensory mechanisms consciously can assist the client and therapist in an “attuned” relationship. Examples include sharing a joke(intimacy without threat) or sharing a fragrance of essential oils (olfactory). Understanding the neurobiology of trauma can guide a therapist to use this information to enhance the trauma work and reduce the client’s shame, and confusion -both pivotal aspects of healing from trauma.
I use Dr. Porges Safe and Sound Protocol with my clients exactly for this reason! It is profound and so helpful to clients (and the clinician!)…
You can access the system & training through Integrated Listening Systems…
Wow. This is great! Can you recommend any particular pieces of music as examples? Something perhaps that can be playing quietly in the background dieting a session? Thank you
I don’t usually have a problem with this, since my work is hypnosis. If trauma is the presenting problem, I don’t conduct a cognitive pre-induction, but go directly into a relaxation followed by a hypnosis session, and do some inner child reassuring visual imagery.
I have changed the position of our chairs so that they are side by side but with some distance, I have dimmed the lights and offered the client a blanket, and I have closed my eyes for the duration of the session and allowed the client to take the lead, all in an attempt to diminish stimulation, create a space that feels safe, and offer the client control.
In my own experience, speaking with a therapist who is blind provided a very safe space for me. It wasn’t until I had gone through the experience that I realized how intrusive direct eye contact can feel, and how much judgment can come and how vulnerable you can feel from simply having a person look at you.
So, with some clients, I suggest that we change the physical environment in my office as a way to increase safety and decrease vulnerability.
Dance.
DanceLifeMaps.
For less traumatized individuals, and perhaps even them, you can also use listening to music, art, or discussion of hobbies as part of building a relationship with the client, especially if you have appreciation and knowledge of what interests them. When they join you in a conversation about what they enjoy doing, or listening to, you immediately see them relax and can observe their breathing change- even get excited….I have a gay couple who feel very ostracized and alienated from the culture they live in and we always engage in taboo subjects (politics) as it makes them feel they are not so alone.
This is also one of the many reasons art therapy is so effective in trauma treatment. Clients are able to focus on what they’re creating and they’re so much more comfortable speaking about the unspeakable. I see this daily with my clients and the ability to hold gaze increases as shame decreases and they recognize they’re safe.
Shannon Bradley, Licensed Creative Arts Therapist
Wishing I could choose ‘creative arts therapist’ from the professions list.
Totally agree. I work with veterans with war related trauma using art therapy in ontario. They engage with the art and we share the experience as client and therapist.
Well said, Shannon. I am always searching for a fitting title in those lists! I would add as well that the CAT work is a separate discipline that has its own set of competencies in which arts therapists are specifically trained. Simply adding the arts to sessions without knowing how to contain can be equally triggering. Consult with your local creative arts therapist, they could be a tremendous resource!
Valerie Blanc, Board-Certified Dance/movement Therapist
That is a reason why in hypnosis we Let choose the cliënt to open or close the een.
I think a couple of other factors might include same gender to gender approaches for pastors to at least be aware of. When we visit a client or they come to me i Hug. That is my first response and then i make light convo and make them a cuppa to relax them. Always find something else to start with, depending on circumstance of course (eg safety, emotional state etc). I find a hug from a mother figure/woman to woman is very effective in breaking down barriers as so many don’t have immediate family around. Some great info however i have noticed eye evasion but i usually always maintain eye contact as i demonstrate my concern and listening technique this way. For a male pastor talking to a scared woman in a church i could see how a different approach would be needed and incross gender circumstances. Can’t wait to read your book.
I have been a trauma psychologist for 40 plus years and many many of the thousand trauma clients I have seen are triggered by any touch until a trusting relationship has been formed. Not a good idea to use touch for a long long time . Safety is the first objective to work on with a trauma victim ( whether male female or other). I learned this early on in the late 70’s. Plus the therapist must always ask permission before touching a client or even moving her seat next to a client!! And never ever to say to a trauma survivor “trust me”! I always say “i dont expect you to trust me but I do expect you to test me!! Then attempt to be compassionate
But from as neutral a place as possible.
Roberta Sachs PhD
I agree- I always ask permission before hugging or touching anyone I meet in therapeutic setting. I believe anyone in positions of authority need to be aware & educated about how trauma effects people & how to interact in a non-threatening way.
Great comments above. I would love to speak further with some of them but I’m too far away , in Australia and way too time poor to be able to do it. So sorry about it too!
Great comments above. I would love to speak further with some of them but I’m too far away , in Australia and way too time poor to be able to do it. So sorry about it too!
It is my mission to bring sound sessions, or sound meditations, as i like to call them, to the mainstream. The path to the body and trauma release, comes in different ways. But music, is one of the kindest and gentlest, and harkens back to the mother’s soothing lullaby.
I agree!
thank you for sharing those lines, will be interested to hear for more. May be using this as lyric as vocal and put in music, this would sounds amazingly in therapy “… Drop into the body. Let go the pain. Push, reach, grasp, pull. Resiliant reality….” “Sounds of silence” or “Boxer” of Simon and Garfunkel are perfect sounds for music therapy, i THINK. So many selection, and use of them for such occasion.
A very powerful and good suggestion of using the music , this also could help client to relax and calm down as well. Thanks for the information.
Soften my gaze. Seats not very close, giving them space, not looking directly at them and often encourage them to look away or in another direction, should they wish to not look at me, sometimes to lie down on couch and cover with warm blankets, with gaze naturally away from them when they are on couch, however, this is only when they choose it, I only invite them should they wish not to look at me. Always to give them choice as this was often a central aspect of their abuse/trauma, having had no choice and being stuck in horrific situations.
Thanks Ruth! I’ll have to give music therapy a definite try! Usually with clients who have experienced trauma, I tell them that we’ll go slowly in our therapy and I encourage them to let me know if there comes a time we’re working too quickly for their comfort. We begin our work with learning coping skills so they feel more confident in being able to eventually process past trauma and cope in the present with triggers that cause them fear and anxiety.
Great article! I will check Stephen’s book. Thanks !!
Why do clients (such as me) refuse to listen to any kind of music?? Because it triggers their emotions? I was not aware that I ran away from music for a long time while I was attached to music for years before.
For some people, sensitivity to sound increases when hyper-aroused. There are some barely audible music used in treatment that stimulate alternating sides of the brain that can be helpful in allowing unintegrated memories (including sensory ones) to be processed. I’ve seen it used in conjunction with brain-spotting. Yoga works for many people for calming their systems, but in places where sensory memories are help somatically, yoga can be highly dysregulating. Having to close one’s eyes to maintain in a session suggests that the sensations are too intense to allow any additional sensory feedback. Borrowing from the bodywork tradition of Alexander technique: eyes should be able to be open so what is learned and processed can be taken forward into all daily functions. Each person’s survival response to trauma is different, and healing may also require different approaches at different times. In general, non-verbal methods allow for accessing the non-verbal memories or the ones where prior efforts to verbalize have stopped at the moment of most intense fear, resulting in re-traumatization. The really important thing has to be that whatever is done in therapy is a good fit for the individual in that moment of time and helps move the person forward, empowers the individual to be in their window of tolerance where (s)he can tolerate thoughts, feelings, and function adequately in the present. In working with individuals with trauma, our challenge is to ensure that whatever comes up in therapy (whether emotional, cognitive, or physical) is adequately contained so when that person leaves the session, (s)he can function well enough and continue to return to do the work necessary for living well and recovering from their trauma, so the past and future do not intrude and control their present life experiences.
Please be careful using music that stimulates two different sides of the brain at once (bi-aural) with pts who have epilepsy. It can bring about seizure activity. This may include migraine sufferers and many others with “generalized brain irritability.”
The same is true for clients with brain injury, many of whom are at risk for post-traumatic seizures. I recommend assessing for a history of brain injury. When you begin to ask clients about this history you may be surprised at what you find in the general population. In the DV population, most women have had many (an initial research study showed 81% had too many traumatic brain injuries to count). In this population watch also for a history of having been strangled which often results in anoxic brain injury. I clear any bilateral treatments with the client’s neurologist. However many BI survivors have never been diagnosed and should be.
Good point. Everyone is different. Maybe the support worker should ask first 🙂
I agree with Stephen Porges. I think that approaching the traumatized brain from anOTHER place (which processes music), can avoid direct interaction with the physical/chemical/neurological part that stores the trauma, thereby diverting away from the fear and distrust that sits there, and so, can work it’s caring magic coming full circle, to integrate fresh emotions/perceptions without the distrust inherent in the original storage locker of trauma.
Perhaps the thing is that there is not ONE way to work through and with trauma. Different things work for differnt people. Music could work for some people but not for all. For me it is one of the biggest triggers there is growing up with abusive parentes who were much into music and who forced me to become a musician.